Panel Study of Effects of Changes in Nursing on Patient Outcomes. The organization and practice of nursing have substantial positive effects on patient care and patient outcomes. As a result of our NINR-sponsored research program continually funded since 1997, organization-based nursing interventions are now more often considered as potential solutions to poor quality and unsafe care. Organizational factors include nurse education, via preferential hiring practices and educational benefits to employees~ nurse staffing, an evolving industry standard that has been the focus of legislation~ human resource policies which determine nursing skill mix~ and the nursing work environment-the organizational practices fostering the autonomy and authority required for nurses to translate their education and experience into effective nursing care. In large, multi-state surveys of US nurses conducted in 1999 and in 2006, we have applied innovative sampling, aggregation, and measurement methods to provide rich information on nursing never before available for large numbers of healthcare organizations that is linked to patient outcomes to document the empirical relationship between nursing and outcomes. These data have been used to answer a range of compelling practice and policy questions about the contributions of nurses to safe, effective care. This application is an efficient, innovative extension of our line of research creating a large study of the impact of change in nursing factors on outcomes, seeking to determine more about causality in order to spur implementation of recommendations emerging from research. We will replicate in 2014 measurements made in 2006 (and 1999 in Pennsylvania) across approximately 665 hospitals and hundreds of nursing homes and home care agencies in four large states with measurement before and after the national economic downturn and the implementation of the Affordable Care Act. The great strength of the application is that in creating a panel of organizational observations, we can see where change has occurred and why. Specific aims are to: 1) Collect data from random samples of nurses in CA, FL, NJ, and PA~ 2) Examine organizational-level changes over time in nurse inputs in (a) education, (b) staffing, (c) skill mix, and (d) work environment between 1999, 2006, and 2014~ 3) Estimate the effects of organizational-level changes on outcomes for patients including minorities and those with chronic illnesses and determine whether lesser improvement in nursing resources in minority serving hospitals has widened the disparity in outcomes between white and minority patients~ and 4) Determine the effects of nursing factors in nursing home and home health agency patient outcomes while accounting for variation in patient clinical severity and complexity. The overarching aim of the proposed study is to determine points of comparatively low-cost organizational leverage of nursing inputs to improve patient outcomes.